Patient Information
Name ____________________________________
Social Security # ____________________
Address ___________________________________
Date of Birth ______________________
City __________________ State _____ Zip ______
Sex ______
Marital Status _________
Home Phone # ______________ Work Phone # ______________ Cell# __________________
Employer _____________________________
Occupation ________________________
Employed: __ Full Time __ Part Time __ Retired
Student: __ Full Time __ Part Time
Person to Notify in an Emergency ____________________________________________
Relationship _________________ Phone Number _______________________________
Primary Care Physician ________________________
Referring Physician ________________
Insurance Information:
Primary Insurance ___________________________
Are you the policyholder? _____Yes ____No
(*this information is NOT on the card*)
If not, policyholder’s name? _____________________ Relationship to Patient ______________
Policyholder Date of Birth ______________________ Policyholder Employer ______________
Secondary Insurance _________________________
Are you the policyholder? _____Yes ____No
If not, policyholder’s name? _____________________ Relationship to Patient _______________
Policyholder Date of Birth ______________________ Policyholder Employer ______________
Insurance Authorization & Information Release
I hereby authorize St. Agnes Healthcare to release information from my records to persons who have need for this
information such as insurance companies, doctors, and other agencies or professionals involved in my care. St. Agnes
Healthcare personnel are authorized to determine which persons or agencies are in need of such information. I hereby
authorize Medicare, Medicaid and/or any insurance company(s) to pay St. Agnes Healthcare directly for services
provided. I agree to accept financial responsibility for services provided at St. Agnes Healthcare for the patient.
Signature: _____________________________________________________Date:__________________________
Notice of Privacy Practices/Financial Policy Receipt: I hereby acknowledge that I have received a copy of the St. Agnes
Healthcare Joint Notice of Privacy Practices & the Maryland Surgeons Financial Policy.
Signature: ____________________________________________________________ Date:____________________________
Acknowledgement and Consent
____________________________________
Patient Name – PLEASE PRINT
__________________
Date of Birth
By signing this form, I consent to MARYLAND SURGEONS/St. Agnes Healthcare use and disclosure of
protected health information about me to the persons listed below. I understand that I have the right to
revoke this consent in writing, except where MARYLAND SURGEONS/St. Agnes Healthcare has already
made disclosures in trust on my prior consent.
____________________________________
Signature
____________________
Date
Please list family members or others with whom we may discuss your medical information or account
information. Please designate by your X in the appropriate column, which information we may
discuss with each party listed.
Name
Relationship
Medical
Account
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Patient Name: _______________________________
Date of Birth: _________________
Reviewed by Physician: ________________
Today’s Date: ________________________
MARYLAND SURGEONS
MEDICAL AND FAMILY HISTORY FORM
Name: _________________________________________
Today’s date: __________________________
Date of Birth: ___________________ Age:____________
Primary Care Physician:__________________
Reason for Visit: ________________________________
Referring Physician:_____________________
How long have you had this complaint or symptoms? _________________
Past or Present Medical Problems:
 Anemia
 Crohn’s disease
 Arthritis
 Depression
 Asthma
 Diabetes
 Cancer
 Diverticulitis
 Cataracts
 DVT
 Chronic anxiety
 Emphysema
 Chronic cough
 Fatty liver
 Chronic lung disease
 Frequent urinary infections
 Cirrhosis of liver
 Gallstones
 Colon cancer
 Groin hernia
 Colon polyps
 Heart attack
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Heart murmur
Hepatitis
Hiatal hernia
High blood pressure
High cholesterol
High triglycerides
HIV/AIDS
Irregular heart beat
Irritable bowel syndrome
Kidney disease/failure
Kidney infection
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Kidney stones
Migraines
Multiple Sclerosis
Osteoporosis
Ovarian cyst
Pancreatitis
Parkinson’s disease
Phlebitis
Pneumonia
Pulmonary embolism
Reflux
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Rheumatic fever
Seizures
Sexually transmitted disease
Skin cancer
Sleep apnea
Stomach/duodenal ulcer
Stroke or paralysis
TB skin test positive
Thyroid disease
Transfusions
Ulcerative colitis
Please list all prescription or over the counter medications you are currently taking on the Surgery Allergy Medication Form
Social History Marital Status:
 Single
 Married
 Divorced
 Widowed
Social History Alcohol:
 Never
 More than 2 days/week
 Rarely
 Less than 2 days/week
 Daily
 I quit using alcohol
Family History:
Bleeding tendency
Cancer
Colitis
Colon cancer
Age at diagnosis
Colon polyps
Crohn’s disease
Deceased – at what age
Diabetes
Heart trouble
High blood pressure
Stomach cancer
Thyroid disease
Ulcer disease
Other
Social History Tobacco:
 I use tobacco products: ____ packs per day
 I have never used tobacco products
 Separated
Social History Recreational Drugs:
 I am currently using recreational drugs
Soc
Father
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Social History Caffeine:
 I use caffeine products
_____ times per day
Social History Occupation:
Patient occupation ______________
Is today’s visit due to a work related
Injury?
 Yes
 No
Mother
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Brother
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 I quit using tobacco products
Social History Exercise:
 I do not exercise
 I exercise ______ times per week
Sister
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Grandparents
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Patient Name_____________________________________-_
REVIEW OF SYSTEMS
Please circle any illness or problems that you are currently experiencing.
GENERAL
□ NONE
Fever, chills, night sweats, fatigue, weight gain, weight loss, poor
appetite, other:______________
EYES
□ NONE
Blindness, change in vision, inflammation, poor vision,
other: _______________
EAR/NOSE/THROAT
□ NONE
Bleeding gums, hearing loss, hoarseness, nosebleeds, ringing in ear,
other:____________
RESPIRATORY
□ NONE
Chronic cough, coughing up blood, wheezing,
recent oxygen or steroid use, other:_____________
CARDIOVASCULAR
□ NONE
Abnormal EKG, chest pain with activity, shortness of breath, pain in
legs with walking, swelling in legs, irregular heartbeat, TIA/stroke,
other:__________________
GASTROINTESTINAL
□ NONE
Abdominal pain, nausea, vomiting, blood in stool, change in bowel
habits, heartburn, yellow eyes/ skin, diarrhea, constipation,
other:________________
GENITOURINARY
□ NONE
Blood in urine, frequency, prostate or testicular problem, heavy
menstruation, other:___________
MUSCULOSKELETAL
□ NONE
Back pain, broken bones, disc problem, swollen joints, arthritis,
other:______________
SKIN
□ NONE
Rash, itching, tattoos, skin infection, recurrent boils, other:________
NEUROLOGICAL
□ NONE
Headaches, chronic numbness / tingling, dizziness, weakness in arms
or legs, seizures, other:______________
PSYCHIATRIC
□ NONE
Depression, anxiety, abnormal sleep, nervous breakdown,
other:______________
HEMATOLOGIC
□ NONE
Easy bruising, blood clots, transfusions, enlarged glands,
other:________________________
ENDOCRINE
□ NONE
Diabetes, high blood sugar, goiter, thyroid issues, abnormally hot or
cold, breast enlargement or pain, excessive thirst,
other:____________
Directions to Maryland Surgeons Locations
Catonsville Office
Catonsville Medical Center
716 Maiden Choice Lane, Suite 202
Catonsville, MD 21228
Phone: 443.546.1600
Fax: 410.719.0094
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Directions: Baltimore Beltway 695 to Exit 12 Wilkens Avenue East. Turn left at the 1st traffic
light onto Maiden Choice Lane. Travel approximately 1/8 of a mile on Maiden Choice Lane past
Charlestown Retirement Center. Turn left into the Maiden Choice Medical Center. Our building
number is 716, which is on the right.
Columbia Office
Medical Pavilion at Howard County
10710 Charter Drive, Suite 230
Columbia, MD 21044
Phone: 443.546.1600
Fax: 443.546.1616
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The Medical Pavilion at Howard County (MPHC) is conveniently located in Columbia on
Charter Drive, just off Hickory Ridge Road. It is adjacent to Howard County General Hospital
and Howard Community College.
Local directions:
From The Mall in Columbia drive westbound on Little Patuxent Parkway (Route 175).
Continue past Howard County General Hospital and turn left onto Cedar Lane.
Turn left onto Hickory Ridge Road.
Turn left onto Charter Drive and continue to the MPHC, which is the second building on the
right.
From Route 32:
Exit onto Cedar Lane and continue to Hickory Ridge Road.
Turn right onto Hickory Ridge Road.
Turn left onto Charter Drive and continue to the MPHC, which is the second building on the
right.
From all other points:
Take Route 29 towards Columbia.
Exit onto Broken Land Parkway toward Columbia Town Center/Merriweather Post Pavilion.
Turn left onto Hickory Ridge Road.
Turn right onto Charter Drive and continue to the MPHC, which is the second building on the
right.
Financial Policy
Maryland Surgeons
Patient Financial Policy
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We have outlined our financial policy below. If you have any questions about the policy, please
discuss them with our Patient Accounting Department. We are dedicated to providing the best
possible care and service to you and regard your complete understanding of your financial
responsibilities as an essential element of your care and treatment.
Full payment of any amount that is your financial responsibility is due at time of service. For
your convenience, we will accept VISA, Discover and MasterCard.
We have a participating agreement with many insurers and other health plans. We will bill those
plans for whom we have an agreement and will require you to pay the designated co-payment at
the time of service.
We will collect the co-payment when you arrive for your appointment. If your insurance plan
requires you to have a written referral, we must have the referral before the service is rendered in
order for the service to be covered. If the appropriate referral and/or co-payment are not
present, the visit will be rescheduled, unless there is an immediate or urgent medical need for
treatment.
As a courtesy, we will file your insurance claim for you with insurance companies with whom we
do not have a participating contract. We will bill you directly for any patient liability; that is,
applicable deductible, copays, coinsurance, etc. If your plan is not an HMO and your insurance
company does not pay within six months from date of service, we will look to you for payment.
All health plans are not the same and do not cover the same services. In the event you do not
have HMO coverage and your health plan determines a service to be "non-covered,” you may be
responsible for the complete charge. Payment is due upon receipt of a statement from our
office. For services that are known to be non-covered by an HMO before they are rendered,
you will be required to sign a financial responsibility form acknowledging your responsibility for
payment.
If you wish to see our doctors for consultation and you are not covered by health insurance, all
fees are to be paid at time of service. If you require surgery and you are not covered by health
insurance, you must contact our Patient Accounting Department before the surgery will be
scheduled to make payment arrangements. A deposit is required before the surgery.
Accounts not paid within our routine billing cycle of ninety-one days will be turned to
collections. These accounts will be subject to additional fees – collection fees, legal fees and
interest.
If at any time, during the course of treatment your healthcare coverage changes, please notify us
immediately. Each insurance plan has different requirements for authorization and precertification of services. Some insurance plans require that certain procedures be performed by
particular providers or in certain facilities with whom they have contracted in order to be
covered. It is essential that we have correct insurance information when scheduling any
procedure for you.
If at any time you are unable to make payment of the amounts you have been billed, call us as
soon as possible to discuss the situation in order to avoid unnecessary collection and legal costs.
There is a $35.00 fee for any returned checks.
There may be a $100 fee for cancellation of surgery, for reasons other than medical.
U:MDSurgeons/Forms/Financial Policy 02/28/2012